The Company Behind Many Surprise Emergency Room Bills

A study by Yale researchers found that the rate of out-of-network doctor’s bills for customers of a big insurer jumped when EmCare entered a hospital.

Comments: 231

  1. This is just the tip of the iceberg. Keep investigating medical billing practices and you will find many abuses, not only in emergency care, but in hospital billing and in the billing practices of individual and groups of physicians.

  2. Please, please keep investigating as possibly suggested. Even from outside the US the healthcare system seems unacceptable both in terms of the comparative costs and in terms of the comparative outcomes. This is not the America I used to think I knew.

  3. Famdoc,

    Former NYT writer Elisabeth Rosenthal has largely already done this in a story published last spring:

    https://www.nytimes.com/2017/03/29/magazine/those-indecipherable-medical...

    Anyone who isn't spitting mad after reading this either doesn't have a pulse or is one of the greed mongers profiting from runaway costs with no effective checks or balances.

    Medicare for everyone.

  4. The Governor of Florida was head of a hospital corporation that over billed the government for billions of dollars of Medicare bills. In the republican party, where every businessman is "Jesus Christ businessman", there is only blind trust by their voters. Anyway the healthcare system seems ripe for privatizing so no one ever gets health care and republicans only reap profits. Looks like a win win to me!

  5. I live in a rural area in Arkansas and have had multiple parishioners in my church suffer this sticker shock. Hospital is in network, ambulance covered, tests covered, but the ER doctor is out of network. Many of these persons do not have the resources to pay these heightened bills.

  6. As a physician with 35 years under my belt and with over 5 years of ER experience before going into primary care, all I can say is that this is as appalling as it is predictable. For profit, unregulated "market based" health care will ALWAYS result in these sorts of systemic corporate abuses. There is a simple solution: SINGLE PAYER.

  7. Single payer has some benefits, but it would not change this. Single payer does not mean that medical providers cannot charge as much as they want.

  8. An established benefit/program is already in place: Medicare. Medicare operates at a lower cost than private insurers; it has excellent record keeping; coverage is universal and regulated. Truman had to fight to get Medicare in place; now we have it and should expand it to cover all Americans citizens, no age barriers. If that is socialized medicine, what is Social Security? European countries have universal care; the current problem they have is coming from the mass migration of poor from war torn and drought impacted countries. Their health care systems were never designed to accommodate the world's population.

  9. Yes. FOR PROFIT. Not for care. Or, you'll get the most expensive care they can give you because they can make more profit. Or, they will cut corners somewhere (everywhere?) because...more profit. The first, or ONLY, concern of a for-profit company is more profit. Everything else is secondary.

    Your health? Secondary. Your well-being? Secondary. Your financial ability to pay or afford care? Secondary.

    What is the primary concern? MORE PROFIT.

  10. This is why Republicans want smaller government: So that corporations can make obscene criminal profits and pay bribes for campaigns.

  11. This is why DEMOCRATS don't want Single Payer or Medicare For All: So that corporations can make obscene criminal profits and pay bribes for campaigns. WAKE UP.

  12. Greg Gerner, you need to wake up. You offer no facts to support your claims about Democrats. All the Democratic voters and politicians I know and support favor universal health care. A survey of nations with universal coverage will show there are multiple ways to achieve it. Medicare for All would be ONE excellent approach, but not necessarily the ONLY one. I am deeply grateful to the Democrats who passed the ACA, which (1) helped save my eyesight while I was self-employed; and (2) changed the conversation about health care in America by offering more protection to more Americans than ever before. Nothing happens instantly in a country as big and complicated as ours. Democrats want what you want; Republicans don't. It's that simple .No third party vote will accomplish it. So your choice is betweeen one possible and two impossibles. Me, I vote for the possible and push it my direction, over decades if necessary. You can throw up your hands in righteous disgust with that, and see how far it gets you.

  13. That is exactly right. The American healthcare system IS the best in the world -- at extracting money. And that's the way a lot of people want it.

  14. What is wrong with hospital administrators? If you can't run your ER economically, what in the world would make you think that by adding a profit driven middleman, it's going to run at lower cost? It won't. It will run at a higher cost, and since the middle man is profit driven, they will charge the patients as much as they think they can get away with.

    The solution is to keep the ER operations in house, and offer salaries for staff sufficient to attract the staff you need, and adjust your non-profit-driven costs accordingly. People may not be happy with the resulting modest bill increase, but it won't be the 3.5 times increase cited in this article.

  15. Tyrone,
    As someone who has recruited physicians, there is an acute shortage of doctors in the US. There are not enough doctors to fill the needs so companies are forced to hire outside firms to staff their ER because they can't find enough local doctors to do it. It's not as simple as just keeping in in-house. If they could, they would.

  16. When you contract out to physician groups you don't pay their salaries, they get paid off reimbursements from claims and you no longer have to pay for administrative overhead (HR, billing/coding, quality programs, etc.)

    I work for a medical billing company owned by a physician group, I'm a software developer making a living like everyone else, but I genuinely believe our physicians provide top-notch care while saving both the hospital and patients money. We contract with many insurance networks, have strict quality programs for both our physicians and our billing/coding personnel to ensure patients are cared for and we bill appropriately - we even get higher reimbursement rates from Medicare due to our performance in quality measures and reporting. We even have financial hardship guidelines working on sliding income scales to help un/underinsured patients who can't afford a huge physician bill and give patients information on enrolling in Medicaid if they seem to qualify, you can't get milk from a rock so it's both in our best interest and the interest of the patient to try to make the best of the situation rather than saying "here's your bill, now pay up".

    Of course, I can only speak for my employer - physician staffing is a competitive field, but there ARE groups and billing companies out there who do it ethically and try to balance the needs of all parties involved.

  17. Anita,
    So where are these outside firms getting their doctors from? If there is a shortage it has to be a zero-sum game.

    Are all these doctors itinerant-staying in one place for a short-time? Are all these hospitals in rural/poor areas?

  18. The general public would probably be surprised if they realized how much in ourhealth care system is based on revenue generation relative to how much is based on what actually works.

  19. Profits? Lot's of bills for NOTHING! The GOP does't like Workman's Compensation. When I was injured at work, there were bills from doctors I never saw. I reported it to my Union and company, and lot's of bills got dropped. Scamming by medical companies and doctors is epidemic.

  20. I own a healthcare advocacy, and we are infuriated on a regular basis by mystery billing. EmCare is deliberate and intentional in its efforts to defraud unsuspecting patients, as are many providers, insurers and manufacturers within the healthcare space.

    How do they get away with it? Just ask our Congress and Administration.

    Get a $1200 ER bill? Don't look to your insurer to help you. Sure, they've negotiated costs with the hospital but will not step in when you're price gouged by the EmCares and hospital groups. You either pay, fight, or damage your credit. We overpay an estimated $58 billion a year in medical debt we don't owe.

    Need a cure for Hep C? Shell out close to $100,000 here because your insurer won't cover it, hope for a new liver or go to India and pay $400 for the same treatment. Our government does nothing to control outrageous pharmaceutical and device costs. We basically bankroll the rest of the world.

    Denied a claim by your insurance company that should be covered? Federal and state insurance agencies are nothing more than paper tigers. If you appeal your denial, you'll get what you should have received in the first place 56% of the time when the insurer overturns its own denial.

    50% - 80% of all medical bills contain errors. Chances are, you'll get stuck paying what you don't owe. The government doesn't do anything to stop this fraud.

    Instead, Congress tries to pass a tax cut for the rich disguised as healthcare reform. Disgusting.

  21. Sarah,
    I'm curious what your medical background is.
    MIMA

  22. You are right about the insurance company not helping fight these outrageous charges. Even for in-network charges, all the insurance company will do is reduce billed charges to negotiated charges and send you the bill for deductible. If you point out the duplicate charges or strange items on the bill, they won't help as long as the total is within your deductible.

  23. Thank you for this enlightening article and Ms O leary thank you for your spot on comment. Trying to fight the Insurance company "Paper Tiger" and provider's billing is indeed exhausting. How folks dealing with illness, financial stress ,and the normal work/ family life is beyond me. Endless phone calls will get you no where. It is time and productivity wasted for everyone. Ive finally decided to call my local senator for help navigating the maze of trouble in resolving issues. Lets get rid of the for profit
    publicly traded model of healthcare. Understandably, providers need to earn a living but we have runaway greed happening. Lets hope the pendulum is swinging toward single payer.

  24. Yes the Republicans and their organs are all about sneaky people being able to make a huge amount of money for doing nothing that contributes to a positive outcome - i.e. - health insurers and money managers. These are big areas that are contrived, unnecessary, and must be brought to heel or put out of existence.

  25. What is the difference between EM Care and La Cosa Nostra? Why are our prosecutors, regulators and politicians going after them under racketeering rather then preying upon poor people with limited resources.

  26. It is against EmCare's deeply religious principles to charge low fees. It is against the GOPs deeply held religious beliefs to not allow gouging of people who have no choice.

    It is a first amendment thing, you know. You guys aren't against the Constintution, are ya?

  27. I serve on my community hospitals' Community Quality Council. The hospital administrator serves on this committee in addition to others in management. Trust me, Em Care will be a topic of conversation and discussion at our next meeting. The community public deserves to know if their hospital uses these services (which I don't think ours does) and deserves to know why if they do and other details.

    Wondering if down the road the next story about EmCare will be about fraud.

  28. Considering how large a percentage of people needing emergency care are elderly, I think this article should have at least mentioned whether or not EmCare accepts Medicare rates.

  29. In France there are no insurance company discounts and no out of network providers. The providers charge the same fee for the same service to all patients. There is a better and fairer way.

  30. France never had the health care industry that America does. Do you think the American healthcare industry is going to accept making the same amount of money across the board?

    I think everyone needs a dose of reality when it comes to understanding why Single Payer will never happen in America.

  31. I was recently in Paris and had to go to the emergency room. Being American, I had to pay out of pocket. The total cost for two ambulance rides (to the hospital and back) and an exam by a physician came to a little over a $100.

    It's a travesty that health care is so expensive in the USA.

  32. Just curious--did EmCare facilities see a jump in positive outcomes? I am not a fan of health care providers gouging their patients, but on the other hand, one way to maintain low costs is to hold care down. This article seems unbalanced to me.

  33. I'd bet my life they did not. This is about taking money from the vulnerable, not quality of care.

  34. Many studies have shown no relationship between cost and outcomes. Read Elisabeth Rosenthal's series Paying Till It Hurts that ran in this newspaper several years ago.

  35. How can we find out if our local hospitals use this company? Are they compelled to tell us if we call them and ask the question?

  36. "Insurers and health care providers typically sign contracts forbidding them to reveal the prices they have agreed to"

    Just mandate the opposite this in the next version of GOP/Trump-care and healthcare will be fixed.

  37. Stark laws, check them out. To stop doctors from unionizing or comparing prices with each other.

  38. There is a cure for this problem if our politicians have the courage to enact it. Simply pass a law stating that "no hospital, physician or other medical care provider participating Medicare or Medicaid shall charge more than 150% of the Medicare-allowed amount for any service or procedure." Since Medicare/Medicaid payments represent over 50% of the typical hospital's revenue, no hospital would sign a contract with the groups who prey on out-of-network patients and/or charge exorbitant fees. The 150% payment level is generous and exceeds almost all insurers' reimbursements. They would, as they should, quickly go extinct.

  39. lets do the same with lawyers. their fee across the country at 150% the federal rate.

  40. Well then, let's do it for all professions. We could define what is fair payment for everything, from plumbers to movie stars (and including columnists), and allow little leeway in pay range.

  41. Thank you for bringing to light on of the most pernicious, unethical problems that patients face. This is not confined to ED services.This occurs in massive amounts in offices and clinics throughout the USA. The underlying problem is that patients are not informed of the potential costs, they are not given a choice of potential providers who do take their coverage, and last (but not least) the electronic medical record makes it so easy to bill for service never rendered. Just a click of the mouse allows the MD to bill at a level 4 visit for the simple ankle sprain. Many hospitals are complicit in this fraud.They know it goes on but excuse themselves from responsibility by saying, "Physician billing is not our business." Turning a blind eye is evil. No wonder we are going broke.

  42. If a level four is supposed to take, say a 1/2 hour, and overseer added up the level 4 time periods billed each day, and it was more than the time given the patients in that whole day, and there was repercussion for such billing, it would stop. Why is this not one of the quality measures EMR's are checking? This might actually be valuable, as compared to a lot of others.

  43. I asked the very same question. There was no interest in looking at this. Most EMRs use inventive billing as a way to increase revenue increased revenue as a selling point, not as a way to monitor for ethical practice. Plus nobody wants to admit it is going on

  44. There is no logical reason why a hospital or a physician should be entitled to bill one patient 4x or more what it bills another for the same service. This is another example of the scams that have grown up in the U.S.'s medical billing system, and go on because medical providers are simply charging the maximum they can get away with. The root problem is perverse incentives. In our third-party payment system, everybody involved has the incentive to raise prices to the hilt and hardly anyone has any incentive, or knowledge, or tools, to exercise cost and billing control. This is the fundamental reason U.S. medical costs have ballooned, and compare so unfavorably to other countries that have not made the same mistake. Strong regulation could help, but it will never happen with Congress in the palm of big-money medical industry donors. We all need to agitate to jump straight to some version of single payer, like every other developed country; it is the only cure for this disease.

  45. Here's a logical reason-most ER patients do not pay their bills. That's what happens when you have a place that is open 24 hrs and must provide care to every single patient who walks through the doors, regardless of their ability to pay. Those who can and do pay are essentially subsidizing the care of those who can't or won't. I had a patient during residency who racked up over $500,000 in during her 2 week stay, which was caused by her alcohol abuse leading to withdrawal that required intubation, ventilation, and intensive care. She used up an exorbitant amount of healthcare resources, and won't ever end up paying a cent. Who gets stuck with those costs? Everyone else who works and pays for their insurance through our increased premiums.

  46. Most developed countries have a hybrid payer system, not single payer. What you are referring to is universal coverage, which IS NOT necessarily single payer. And most of those countries with universal coverage and hybrid payer systems have better health outcomes than the UK, which has equally poor outcomes as the US.

  47. The private, largely unregulated medical system has crossed the point of no return for abuse and exploitation. They deserve what's coming to them, which will be some form of single payer or a highly regulated federalized system (like Germany has). The endless gotchas and landmines for consumers in this systematically corrupt business will never come to an end without strong, pervasive government regulation. We cannot keep spending more than twice what all our peer countries spend per capita and be an economically competitive country. Heck, our life expectancy is down to #31 in the world, just ahead of Cuba at #32; Canada and Australia, the two countries who are closest to us economically and culturally live a stunning 3 years longer on average.

  48. It has nothing to do with healthcare systems: Canadians and Australians "live longer" because they are vastly majority white/asian -- asians naturally live somewhat longer than other racial groups.

    The US has a very large underclass of poor blacks and hispanics, who both historically and genetically have more health problems, and shorter lifespans.

    If you compare "only white middle class Americans" with "only white middle class Canadians, Australians or Europeans" --- we do just as well and even better sometimes.

  49. This is organized crime. These physicians are part of a fraud and should be prosecuted under the RICO act.

  50. Yeah but can you imagine if we had SOCIALISM and all of these people's bills were paid for? Then who would profit off their misfortune?!?! So un-American. #sad

  51. The point is healthcare is cut, first to give more profits to the healthcare industry and now as an attempt to reward donors, who control the government. This does not mean people won't get sick. On a median income of around $30,000 they can't afford this bloated system. So when they do show up very ill what will happen? Back to the ER until that becomes too expensive or the GOP does away with that option. OMG, now what do we do? Die?

  52. EmCare. Enron. It's all the same. American businesses are predatory and are mostly allowed to get away with it. When and if they do get caught, they pay a fine and move on. The potential fines are built into their business plan from the start.

  53. "EmCare. Enron. It's all the same. American businesses are predatory and are mostly allowed to get away with it."
    Most American businesses are not predatory. But we need a free press to call out the ones who are, and aggressive prosecutors to drive them out. Otherwise the magic of the unregulated free market will do the opposite and drive the honest ones out, and your statement will be true. In the meantime, it's vital to draw a bright line between the honest and the corrupt, and do what we can to support the former and shame and boycott the latter.

  54. Certainly not a problem confined to the ED, but the uniqueness of the ED's purpose makes it particularly troubling. Patients usually don't have time to "shop around" for emergency services and providers. It's almost like peeling an onion. My daughter was seen in a local ED about a year ago. $150 copay. But beyond that, a slew of bills from the lab, an out-of-state ER practice, among others. Fortunately, our insurance stepped in, but what if it hadn't for one or more of these providers?

  55. If you don't pay-up within "x" days you get the collection agency on you as well. You don't even have time to argue the bill, your credit score gets lowered. Have to pay-up and fight later. From personal experience.

  56. I am constantly reminded of what Bernie Sanders said: "The business model of Wall Street is fraud."

  57. True. But it's the business model that spurred the War for Independence, and is in our country's DNA. Bernie wants to change that DNA, and maybe the country is ready for a change.

  58. Yes, working as designed, and very well, to extract money from the innocent.

  59. AH HA! Yes the costs are due to the out of control bills based on mythical "codes" and uncontrolled drug costs. Yes, we know this and so do the politicians but 1000 lobbyists working each day and paying millions to keep the con going. 40% of procedures not necessary, drug prices, for same drug, can vary from $40 to $400 in same city. MRI can vary from $2000 to $6000 for same exam. Visit to ER for a headache can cost $3000. Yes we are being robbed and the politicians could care less.

  60. The politicians not only could care less but are paid off through contributors, pacs, etc. to protectant even further deregulate the scheme.

    I can say with certainty that my congressfolk and senators are not looking out for the common good.

  61. What you say is true, but please don't go to the ED for a headache!

  62. The only surprise is that some people are (still) surprised by these findings.

  63. In just about any business, when your vendor farms something out it is on them to pay the contractor not the end customer. For example, if you take your car to an auto repair shop, you expect to pay the shop, not receive bills from individual mechanics.

    This is an element of the health care system that needs strong consumer legal protections. If the hospital makes the decision to contract out labor, then the hospital should be on the hook for paying those contractors out of the money it bills to the patient or their insurance company.

    The behavior described in the article is nothing more than a bait-and-switch tactic.

  64. That's exactly what it is, and why it's only found in specialities the patient have no choice whatsoever over--emergency, anesthesiology, and radiology. The hospitals will find more niche, specific service providers if they can--highly profitable for them and the companies.

  65. Wonderful analogy! Of course, any auto repair shop that did that would be out of business in a flash. Hospitals, on the other hand, have a monopoly on treatment so they don't have to abide by the same rules.

  66. This is what happens whenever a monopoly is created. In the case of the ER, the physician group that holds the contract has a virtual monopoly on the delivery of care. They have an incentive not to sign a contract with an insurance group. Why should they when they have the ability to bill any amount they want. The reasoning that Emcare "allowed a hospital to treat sicker patients" or that "it's a source of dissatisfaction for all...providers" is again just lip service to justify their gaming the system.

    A hospital has a certain level of service it is certified to provide in it's ER. Unless each of the Emcare hospitals changed the level of service from a trauma level center 1, 2 or 3, the service levels are defined. There are ways to manipulate the billing which larger companies have the manpower to do.

    And why would it be a source of dissatisfaction? When the median ER physician is making almost $300,000 per year, they are not being incentivized to lower costs. Instead, if they would rather control the market, i.e. Your only choice when you go to the ER, sign no contracts with the local insurers and bill what they can get away with

  67. Or you can scratch out the portion of the form that says you will be personally responsible for the charges if your insurance company does not pay, and initial the change. Then sign the form. They still have to finish the emergency care being provided. The only time this doesn't work is for the unconscious patient.

  68. My relative had to go an Emergency room, spent 20 min there, they did an EKG. As EKG was normal, we got out from there very fast even though they wanted to do additional tests). Bill was only around 5000 dollars for an EKG. How can we allow these kinds of highway robbery to go on. No wonder our healthcare system will bankrupt the patients and our country. This must be stopped.

  69. Are you willing to pay a lot more in income taxes to have another healthcare system? It's what other countries do.

  70. In a word, yes. I. Am.

  71. Citizen60:
    Yes I'm willing to pay more in taxes. I'm also willing to take funds from the military's toy budget to pay for single payer and improve this country's infrastructure.

  72. There should be a law if there is no choice of a network provider, no surcharge. We are talking ER rooms not elective surgery. It not in a network the insurance contract prices which are much lower than the list price do not apply.
    Perhaps patients should be given the same generous cut Insurance Companies get. Your $2000 bill is a $1200 bill to the Insurance Company,

  73. What would we pay for a car if we had to buy it from a transportation insurance company? We arrest bank robbers. But if they're wearing a white work jacket we don't? This country is so, so bought and sold. It cannot, and will not go on much longer. It is absolutely unsustainable.

  74. End the medical extortion: Medicare for all.

  75. It's the only way, but the citizens of the US must be willing--eager--to pay a lot more than current Medicare costs in taxes. They have been slowly reaching this point over the last 20 years -- almost there!

  76. F. Horne
    Get a Democratic Congress and that might happen.
    MIMA

  77. The article states the EmCare is a 'staffing agency'. One assumes that they are receiving salary, benefits, and other compensation for their services from EmCare.

    Why, then, are they also billing patients directly? This is pure double billing. The patients and their insurers pay hospitals for the services the patients receive; the Hospitals pay EmCare who pays the doctors.

    Then the doctors who have already been paid for their services are allowed to bill the patients directly, patients who have already paid for the services they have received.

    HOW IS THIS LEGAL?

  78. There are two parts for any in-patient claim, professional and facility. Hospitals more often than not these days don't employ their own physicians, they contract to a physician group ("staffing agency") to staff their departments.

    Physician groups make their revenue billing for their services, the money they make from a contract with the hospital (if any) is peanuts.

  79. EmCare pays the doctor. The contract is between EmCare and the hospital. The hospital doesn't bill for the doctor; EmCare bills as a service for its doctors, with the doctor's name on the bill. It's like in a legal or accounting firm. Very common practice in professional staffing and very legal.

  80. the company bills in the dictors name and collects the fee. medicare pays the facility and doctors separetly ny lae

  81. Well. The marketplace works, y'all, and this is just one example of how fully the healthcare industry participates. I don't recall specifics, but does anyone remember the rise in 'Epipen' costs? Again, just another example of the marketplace at work.

    i repeat what I have said on other occasions: I worked in a company with offices in over 120 countries, including all of western Europe. My department rotated personnel from those countries, and Japan, in for two-year stints with us. To a person, they were bewildered by the American healthcare 'system.' All of them thought it as quaint and inefficient at best, and inefficient and absurdly costly at worst.

    Posted comments about laws that should be passed are laughable. By this legislature? With this president? I hope the Democrats are collecting these stories for 2018 and 2020, and will use them in the states where they took place. And remind us, nationally, about what can happen in the great marketplace.

    Single-payer, where are you?

  82. Medicare for everyone may be closer than we all think. Really, it's inevitable. We simply can't keep going on like this, and the current clown show in Washington likely will only speed us to the inevitable as more and more people see the obvious: This emperor has no clothes.

  83. I fully agree. But don't count on the Democrats for help. Democrat (and socialist) Bernie Sanders proposed an alternative, and was dismissed as a unicorn. Candidate Obama promised a "public option" with Obamacare, and dropped it like a hot potato when K Street objected, which is why the ACA is like a house with termites.

  84. Greg Mendel, I know this will sound very strange to you, but I can absolutely favor tax-funded universal coverage, preferably Medicare for all, WITHOUT necessarily favoring Bernie Sanders or any other individual politician. Lots of people have proposed it, dating back to Teddy Roosevelt, but no one, not even Bernie Sanders, has ever come up with a realistic political strategy for getting such a plan passed through both houses of Congress. I agree with Bernie, but he has no more power to accomplish that goal than I do, and no strategy for winning over Congress. Sorry. The idea is not synonymous with one man. Seeing it that way is a distraction from the long game -- the game Obma was playing when he enacted an ACA that provides benefits now precious even to many voters who opposed him.

  85. 'Fiona Scott Morton, a professor at the Yale School of Management and a co-author of the paper, described the strategy as a “kind of ambushing of patients.”'
    ----
    I would simply describe EmCare's practices as racketeering; obtaining or extorting money illegally or carrying on illegal business activities, usually by Organized Crime.

    These practices and the entire American medical extortion industry need to be fully investigated and prosecuted under the Racketeer Influenced and Corrupt Organizations (RICO) law.

  86. Socrates, the entire wealth care industry but most especially the "health insurance" industry practices extortion and ought to be prosecuted under RICO. I've been ambush billed by doctors which makes me think thrice before picking up the phone to see any doctor for any reason. Yet our politicians, cowards that they are, especially the GOP practicing sect of politicians, can't wait to pass legislation making our wealth care system even wealthier. It's the same thing that happened after Gabrielle Giffords was shot and that class of first graders in Newtown, CT: make guns more available to help the NRA and the firearms industry. Here, even as they get shot and need extensive surgery or have a serious illness diagnosed, they still want to give more money to the wealth care industry.

    What is most obvious is that THEY have no idea of the cost of medical care or the cost of going without. They should be put on a diet of high deductible, high co-pay, narrow network, and unresponsive medical care. Then we'll see how fast things change once they have to live like the peasants they so despise.

  87. Problem is -- these activities are not illegal. Immoral and unethical to do this to patients--do those terms mean anything today--definitely. But they are not illegal. The only thing possibly actionable is intent to defraud insurance companies or the government (the Medi's) by up-coding on billing. Try to disprove an up-code in an ER!

  88. Socrates,

    You regularly pontificate on how great ACA is. It would be nice if you would acknowledge that ACA simply helps perpetuate a broken system. EmCare's practices aren't the disease, they are the symptom, and you don't have to look far to see abuses this bad, and worse, that will inevitably flourish in a for-profit, private health care system that is really more anything-goes than any kind of system.

    Medicare for everyone.

  89. It is the "in-network/out of network" that is crazy. We need single payer, in which ALL doctors are "in-network" and doctors are not permitted to practice if they don't participate, as many do with medicare and medicaid now. Dentists, too.

  90. So Stalinists now dream of compelling doctors to participate in collectivist farms, or not work. Instead of breaking up crony capitalist cartels and letting small physician groups thrive again, which will reduce prices due to competition among them.

  91. Oh please. Health care has never been transparent, and price reductions because of "competition" will never happen. It is very hard to price shop health care procedures. All the OECD countries have some form of universal health care or insurance, spend way less money as a percent of GDP with better outcomes. Is there something wrong with that? Can we learn nothing from those other countries?

  92. This is the real problem with our healthcare system, but no one will acknowledge it.

    https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Tren...

    Costs of physicians and hospitals make up the vast majority of our healthcare costs (up to 80%) but these are the costs people complain about the least. While everyone is railing against the drug companies (only 10% of costs), no one is saying what is obvious: our current fee-for-service system is a sham.

    Of course doctors and hospitals are going to order more tests. They get paid more if they do! More services = more fees!

    Of course hospitals are going to hire companies to run their ERs (and any other department they can). When every single thing a doctor or nurse does ("service") is coded individually so it can be charged individually ("fee"), billing is a nightmare. Good, large hospitals put up with the nightmare and negotiate rates with insurers because they can, but a small, regional hospital would much rather hand the whole thing over to EmCare and let the patients suffer the consequences.

    Companies like EmCare thrive because this fee-for-service system creates perverse incentives for hospitals and doctors to gouge patients. Hospitals should move permanently to transparent "diagnosis related" billing and all doctors should be salaried. Time to take away the incentives to over-charge and the excuses about overly complicated billing.

  93. Doctors caring for patients account for less than 10% of the medical industry's revenue. Your 'upto 80%' is misleading to say the least. Of course, there are doctor-administrators and doctor-managers in hospitals, insurers, and medical groups, possibly even in Emcare.

  94. Is anyone surprised? We hardly need a Yale study to inform that a monopoly provider (EmCare) for professional ER services at a particular hospital will maximize revenue by refusing to participate in insurer networks (20% of all ER professional groups do likewise, according to the article) and upcoding..... This is just one small example of the lack of market forces in health delivery that results in enormous price increases in non-governmental financed services. The multi-billion/year, "not for profit" health system cartels (a/k/a your community health system) reward their execs millions in bonuses for consolidation, acquiring physician practices, adding a new "facility overhead" charge after acquiring the practices, raising prices to private insurers, then channeling all diagnostic testing and procedures to the much higher priced, cartel owned facilities. So what else is new? Medicare and Medicaid dictate prices for all services, including ER professional. Then the professional group will "cost shift" to private insurers. That's how the racket works. That is why only price controls or a sole payer system will curb ever spiraling private health service prices in the US. The only real surprise is why US employers, who end up paying a disproportionate share of US health costs (which make them non-competitive internationally) tolerate the racket.

  95. I'm trying to understand. I go to the ER; at this point I have o choice but to sek medical attention. The clerk at the front desk tells me that the hospital accepts my insurance; presumably I already knew this or certainly assumed as much. What nobody tells me is that the physicin is actully employed by a third party who may or may not have a reimbursement agreement with my insurer, which leaves me exposed to any charges the third party imposes for the physician's services. This is astonishing and I am confident those charges are uncollectible on the basis of consumer fraud. If the hospital represents itself as under contract with my insurer, I should be entitled to assume that ER services are included.

  96. Many practices that would be fraud or borderline fraud in other markets are not fraud in the medical/insurance industry because the market had become accustomed to accept them as normal.

  97. "should be" and "assumed" are the key words. You are not entitled to anything legally, except emergency care to stabilize your condition only to the point that you can be safely transferred to another hospital for your care. That is all the hospital is legally obligated to provide.
    The patient--the consumer--has no legal authority to tell the hospital how to conduct or manage its business. And it is a business, even the non-profits. The only legal option the patient has is to not "do business" with the hospital; which, of course, an unconscious or injured patient cannot choose to do. It's why the delivery of healthcare cannot be a consumer-driven market; but the rest of the US economy is.

  98. There is often some fine print in the admission document you sign, or sometimes posted in the wall in the admission clerk's office, to the effect that many of the physicians and other professionals practicing in the hospital are independent contractors who will bill you separately for their services. Not that that does you a whole lot of good when you are bleeding or in pain and may not even know what type of treatment you need.

  99. This article is a very good illustration of why we need to go to a single-payer system. Under such a system there would no longer be "in network" and "out of network" nor would there be byzantine deals between insurers and providers. Charges and coverage would be transparent to all; no surprises.

  100. Heathcare service is like police service and firefighter service. It is there to protect Americans from harm to life and liberty and to empower them in their pursuit of happiness. It supports our declaration that all Americans are created equal.

    Required Results of New Healthcare Act:

    One: Expand the number of people covered.
    Two: Do not reduce the benefits of any person now eligible.
    Three: Do not increase the costs to any person now covered.
    Four: Pre-existing conditions covered.
    Five: U. S. Government to negotiate drug, device, and service prices.
    Six: U.S. Government to allow purchasing drugs and devices from foreign sources.
    Seven: Companies that drop participation are not allowed to have any U.S. Government business. https://www.theatlantic.com/health/archive/2017/05/why-so-many-insurers-...
    Eight: Elected officials have the same coverage as ordinary Americans.
    Nine: Preventive Life Style screenings with first visit of a calendar year
    Ten: No restrictions of funding for Planned Parenthood
    Eleven: Better policy on the disposition of “expired”, but still safe and effective drugs.

    One approach would be Medicare/ Medicaid for all Americans.

  101. These companies usually split the coding and staffing components. The ER doctors just try to do their job, but get pushed to upcode everything (phone calls and emails during shifts even). I worked in a similar environment and moved on (not specifically EMCare). The real question is why do so many hospitals contract with such a company? Usually because they offer to reduce expenses for the hospital (lowest bidder). Then, lo and behold, patients get higher bills. The hospital saves money at first, and then finds out why (costs pushed to their patients). I do not feel sorry for these hospital administrators.

  102. And the hospitals can also take the contract to a provider as a Cost--contacting services in the ER and anesthesiology doesn't just saves the hospital administrative time and personnel and hassles, it provides a nice tax write off. Patients cannot chose their ER doctors or anesthesiologist or radiologist -- they must have whoever is on rotation. That's why you see niche services in these particular specialties--no patient choice. Free market at work.

  103. As a medical social worker I pride myself on assisting my families through the bureaucracies of this countries healthcare, but when my child was required to have 2 separate surgeries for hearing loss, my family was billed out of pocket for his anesthesiologist as she was "out of network". When it came to his second surgery, I personally called the anesthesiologist to assure that this would not happen again. I was assured it would not. But it did.

    California has a new law that makes this type of billing illegal. More states most likely to follow.

  104. New York has a "surprise bill" law as well.

    I had a similar experience. I went to a surgeon after checking he was covered by my insurance. He wasn't in the list on my company's website, but he assured me personally that he was, as did his staff. While I was home recovering, I got a check to pay him for $97,000 - against a bill for $147,000. The situation wasn't covered under the surprise bill law because I had an "ongoing relationship" with him. So I asked a friend who was an attorney to put the check in his escrow account and to send a letter saying that as soon as I got a bill accepting the money I had, they'd get it, but until then, it would sit in his escrow account. I also filed the surprise bill paperwork, which is how I found out this type of situation isn't covered. It took them less than two weeks to sign off on accepting the amount my insurance company paid, which I'm sure is exactly what any insurer's negotiated fee would have been.

    Punch line: My insurance company is a US Healthcare company called The Empire Plan, aka United Empire. The surgeon accepted various other UH plans, just not THAT one.

    If our government will not stand up to stampeding health care costs and procedures, then we have to do it ourselves. Until we get a sane and sentient government that allows us universal care.

  105. Why doesn't the free market function to reduce emergency room costs?
    The free market requires that consumers have a choice. If there is only one emergency room nearby or you are mentally incapacitated, then there is no choice. The market fails. More generally, consumers are provided very little information about the price of services or the outcomes to be expected. The supplier holds all the cards in such a system.

  106. I was once a victim of “ambush” billing even when I took deliberate steps to try to avoid it. I was injured in a bicycle crash but not so severely that I couldn’t call my insurer and verify that the hospital I was headed to was in network. I was assured it was.

    Four weeks later I got a bill from a company I had never heard of. It was from the out-of-network radiology practice who x-rayed my shoulder at the in-network hospital. I complained to my insurer about the unexpected bill I got by relying on their advice. They seemed surprised that I was troubled by this but they eventually agreed to cover the expense. This happened to me 15 years ago. It's sad and troubling to hear it's now even worse.

  107. To be fair, it's not really the insurer's fault. They contracted with the hospital and likely had no knowledge that the hospital employed out-of-network providers. That said, insurers should mandate in their contracts with hospitals that if the hospital is in-network, it cannot (nor can anyone working there) bill the patient for out-of-network services.

  108. But in network docs may not be available or be on call in an emergency.

  109. The statistics showing fraudulent billing are compelling

    Why are not this companies executives and its physician employees indicted for fraud?

  110. No one ever wants to blame the doctors, but MDs are the primary beneficiaries of these systems, which are often founded and cooperatively owned by the physicians who work for them. Thus any increase in company profits is an increase in the MD's personal income.

  111. Emergency Dept physicians are pretty well paid (lots of training, shortage of board cert. ER docs, tough job with high stress, etc.), but I wouldn't confuse that with benefitting from the billing practices of a large, publicly traded company. EmCare/Envision is not cooperatively owned by physicians. There are many ER physicians who do not like the large contract management approach; in fact, there's a whole physician membership group that is opposed to it (AAEM).

  112. Patients do not realize that EmCare/Envision Healthcare Holdings is a "for profit" staffing business. What does for profit mean? It means they report earnings to stockholders.

    In this case, EmCare staffs just the ER but many times radiologists, anesthesiologists or any shift work based physician job can be managed by EmCare. Sometimes even an entire hospital is part of a for profit system eg the Health One system here in Denver.

    So why does a hospital need to hire an outside company for staffing purposes? It is often because the hospital itself has mismanaged staffing in the past or has failed to incentivize and adequately recruit for the job. Think about it- an ER needs to be staffed 24/7. What happens when a particularly undesirable shift goes uncovered (eg the night shift on New Years Eve)? Well the risk is that the shift goes uncovered and nothing changes the quality of patient care more than an understaffed hospital.

  113. Good study. This Ambush Billing needs to be outlawed. Think this will get better under Trump? Dream on!

  114. And why are people against single payer universal healthcare?

  115. 1. People who have good, employer health care are afraid of changing things. They need more information about what they have been paying for their health care in lost wages.

    2. Many investors are making a killing investing in
    Health on the market.

    3. Our Govt civil servants are addicted to Health dollars gfowing into their campaign war chests.

  116. I'm not against it but I'm cautious. I'm 67 and still on my company HSA plan. I pay really high taxes as a single person, and I do not collect Medicare.

    You do know how much your taxes would go up to pay for this? I need every penny I can get now to fund my retirement. I have painstakingly cared for my own health and finances and don't mooch off medicare yet. That means no soda pop, no cookies, no candy, no overeatijng, exercise everyday -- and yet I have to pay for your indulgences. and yes, I'm a Democrat.

    Is it fair that my taxes go sky high? A single healthy 67 year old woman?

  117. Leonora: it makes no sense to forgo Medicare -- for one thing, you pay a small penalty for every year you don't enroll.

    With a high deductible HSA, you are in an ideal position to use Medicare for your basic expenses, and then add in the HSA for any non-covered or expense care -- things like dental, vision, hearing.

    I am surprised that a highly educated attorney would not know this. Is it vanity that keeps you from enrolling in the Medicare you PAID FOR over the last 45 years?

    BTW: it's good to stay healthy, but I'm pretty sure you deny yourself every pleasurable thing in life -- at 67! -- because of your vanity about being very slender, and not for "health". (This has a name: orthorexia.)

    Here's a wakeup call: you can starve yourself and live like a monk, but you are going to get old and die anyways.

  118. What is missing here is whether or not patient outcomes improved after the EmCare transition. Oftentimes community EDs are being staffed by non-specialists who are not residency trained board certified emergency physicians. EmCare employs only board certified EPs and that higher standard of care costs more. It is true that the average sprained ankle patient will have to pay more for having the facility staffed by a specialist and will probably receive the same level of care, but the hospital makes that decision so that patients having heart attacks, strokes, traumatic injuries, septic shock, crash deliveries, etc receive a higher level of care. We don't fund fire departments because they get kittens out of trees so well, we pay them 24/7 so that they are available when a real fire occurs. Family practice doctors staffing EDs do well a lot of the time, but the average family practice physician cannot perform key life saving procedures like thoracostomy, central line placement, endotracheal intubation, lateral canthotomy, etc that the emergency specialists do routinely. There is a lot more to this story than is being reported, we as a nation can have cheap emergency care if we want, but it will result in poorer outcomes.

  119. I don't know but I doubt that a fire department sends the owners of the kitten a bill for $500 for getting it out of the tree. Fire department are still considered to be a necessary service for the good of all - and are therefore publicly funded. whereas hospitals and healthcare have become profit centers for shareholders and sleazy manipulators of a system that views patients as ATMs.

  120. Totally agree. We should have a single-payer system and healthcare should be a service like fire, police, etc. As it stands now, healthcare is also largely publicly funded and insurers are an unnecessary middle man. My point was that the article glosses over the value added service that EmCare provides (more skilled physicians). It is the insurance companies that create and sustain this problem by keeping their networks so geographically tight that the vast majority of physician fees get billed as "out of network".

  121. Show me one person who has ever gotten a surprise bill for having the fire dept save their house.
    Emcare's practices are pure greed. Just like Martin Shkreli and the way he jacked up prices for long ago developed life saving medications.

  122. When I retired, our group collected 36% of billing. I was an ER doc for 30 years. Most of billing was never collected.
    The ER is a dumping ground, plain and simple. The all purpose answer for everyone on call.
    This will not change without single payer, and tort reform.

  123. I am still working, my group collects 20%

  124. There should be a law that if a hospital or clinic is an in-network provider, that all bills, regardless of whether the physician or individual provider is themselves in-network or not, be processed as in-network. In all cases, the consumer does not have a choice of the person caring for them. You should not be in a vulnerable position and be forced to research the network status of a provider before allowing them to care for you.

  125. This is another reason why we need single payor universal access. Our fee for service wealth care system creates huge incentives to use the most complex codes so as to get the highest reimbursements possible even if the code is not the correct one in terms of how difficult the treatment is. When medical care is about money instead of about treating the patient and the patient is considered a consumer it's easy to charge as much as possible. It's simple for doctors, hospitals, and ER departments to assume that insurance will cover enough of the cost to make using the highest cost codes on bills. What they don't know or don't care about is how the refusals affect patients willingness to go for treatment for any condition.

    If the wealth care industry is interested in creating a more healthy population they are going about it the wrong way. We will not be able to care for ourselves when we're viewed solely as pockets to pick instead of patients who need care. Just using myself as an example, I haven't used my asthma medication in about 3 years. I haven't been able to go to a doctor for that long. Why? Because of our Byzantine wealth care system that tends to the health of wealth care system rather than the health of patients.

    Until patients needs and health are first, America will continue to have a very unhealthy health care system but an excellent wealth care system. And we can thank both parties for that.

  126. hen3ry: if you are really doing as badly as you say -- unemployed -- why aren't you on Medicaid? You live in a state with generous Medicaid and health care policies. The ACA is still in effect. It doesn't make any sense!!! why suffer? are you a martyr? why live without necessary asthma medications? that's not even a super-expensive type of medication.

    In my area, there are "free clinics" you could go to, even with no insurance or Medicaid -- heck, it would be better to see a doctor, get your meds and then refuse to pay the bill. Yes, your credit would take a hit but you'd STILL BE ALIVE. Asthma at your age is nothing to fool around with.

    Will you have saved money when you end up hospitalized with pneumonia???

    Trump has not been in office for 3 years. What was your excuse 6 months ago under Obama and Obamacare?

  127. Excellent story. Thanks NYT.

  128. "But it acknowledged that surprise billing, as the billing is called when the doctor is unexpectedly not part of an insurance network...."

    If we had a single payer system, LIKE ALL OTHER FIRST WORLD NATIONS ON THE FACE OF THIS EARTH, this would not be an issue. It wouldn't even come up.

  129. Only 3 nations in the world have single payer; none of them are in Europe.

    I wish lefties who keep blurting out "single payer!" would actually bother to learn what it means. (Hint: it does NOT mean "everything is FREE!")

    You can't possibly ever achieve reform -- or single payer -- if you don't know what it means, or mix it up with "universal health care".

    Most nations don't use single payer; they use hybrid systems combining non-profit insurance with very basic government plans -- OR they have purely socialized medicine (like the British NHS) where government owns the hospitals and pays the doctors salaries. Neither of these are "single payer".

  130. Another article pointing out the tremendous problems with American health care. No one wants to blame physicians, but they need to take the lead in a comprehensive overhaul of our system. Physicians have the most at stake as a profession, and know the system. Give physicians the complete tort reform (which means no lawsuits against physicians) they clamor for, then demand transparency in billing, and fees paid for patient outcomes, not merely for expensive procedures.

  131. EmCare said that it allowed hospitals to treat sicker patients when it takes over, and that an increase in such patients explained the higher billing in Newport.

    **********
    Emergency rooms at hospitals taken over by EmCare were turning patients away?

  132. No, the sicker patients were being transferred to larger hospitals. Inpatient facility fees are a revenue generator for hospitals. The ED is considered an outpatient environment, so emergency specialists often allow hospitals to keep patients that they might have otherwise needed to transfer out. For example, if you fall and have a broken rub/collapsed lung, an emergency physician could perform a tube thoracostomy (chest tube) to re-inflate the lung and you could subsequently stay at your small community hospital as an inpatient. In an ED staffed by non-specialists, you would be seen in the ED, but the doctor in the ED may not have the skills necessary to re-inflate the lung and you would hence be transferred to a tertiary care center for definitive care.

  133. We continually blame administrative costs, management costs, external device maker companies as the main reasons health care costs are so high. The reality is that US physicians are as greedy as those in any other profession and demand high rates of pay that in other countries would not be tolerated. These companies that use out of network fees for physicians make huge profits but so do the physicians, themselves. We need caps on all fees related to health care costs and secondly a single payer system. A single payer system would eliminate at least 25% of fees because most of those 'backroom' workers we all see in hospitals and doctors' offices doing whatever it is that they do would be non existent.

  134. Yet another poignant example as to why we desperately need a single payer heath care system.

  135. Following several visits to the surgeon's office, my late father was hospitalized for a couple of days prior to abdominal surgery. During that period a series of unknown physicians entered unannounced, engaged us in two minutes of perfunctory conversation, and vanished. None were part of the surgery team. None approached within four feet of the patient. Poring over the subsequent blizzard of bills I learned these brief extracurricular chats were billed at $500 - $600 a pop.

  136. AN INSURANCE COMPANY That demands that patient information not be disclosed to patients is clearly in violation of the HIPAA laws. Any and all information in any patient's chart is the property of the patient. It does NOT belong to the medical provider. The patient authorizes the medical provider to retain medical information and to maintain its confidentiality. The idea of secret price gouging is infuriating. I hope that EmCare is investigated and shut down, its bosses and owners brought to trial for violating the HIPAA regulations and patients' rights. Who do they think they are inflating charges? Once again the 1% are exploiting and destroying the 99%, especially the middle class.

  137. The practice of hospitals hiring companies to provide doctors and nurses must stop. If you operate a hospital you need to hire your own staff. It is that simple. If you cannot find doctors and nurses to work for you, you have no business running a hospital.
    I went to the ER last year. My insurance covered the visit after I paid my deductible. The doctor was 3rd party, a fact I did not know nor was I told (I was busy suffering from massive chest pains and didn't think to ask for his credentials, silly me!) His organization socked me with a huge bill that nearly gave me a heart attack on the spot!!
    This has to end. It is highly unethical and unprofessional. Robbery. That's all it is.

  138. I wonder if Yale's affiliated, EmCare-staffed hospitals were included in the study...

  139. You should carry a card ATTACHED to your med insurance card saying you DO NOT CONSENT TO OUT OF NETWORK CARE. Better the risk than bankruptcy.

  140. Phenomena like “ambush billing” put the lie to the free market dogma that we are all supposed to shop around for health care and be “smart health care consumers.” How can there be price transparency when the delivery of care is a tangle of contracts and you can’t even be sure who is actually providing care to you?

    These practices have destroyed trust in the whole health care system. Anyone who has ever laid awake in a hospital bed has wondered if you’re there because you need to be, or if you’re just another cow being milked for billings.

  141. I now wonder if EmCare is involved in what happened to me. I went to the emergency room at St. David's in Austin. I gave them my insurance card, & within a month of being released, received a bill from one company, requesting payment of my deductible ($2000) for "emergency services." Began paying that off in installments.

    Then three months later, a separate bill for "emergency services" from a different company arrived; this one demanding around $1500. They claimed that "Medicaid" had denied the claim. I wrote to them, asking exactly what this bill was for, & told them they should have submitted the bill to my insurer, not Medicaid! I sent the bill on to my insurer, & never heard a word back from the billing company.

    Months later, they sent the same bill! Again, I wrote & forwarded the claim to my insurer. My insurer replied, saying that they wouldn't pay it because it had been submitted "too late." The billing company has never replied to any of my emails or letters. They have remained uncommunicative. I told them that I had already paid for "emergency services" at St. David's, & that they needed to specify exactly what they were charging me for. Silence from this company! I am expecting them to hit me with a collection notice, because these companies are leeches.

    This is yet one more instance of the inefficiency of subcontracting out to private companies. They are accountable to no one & are utterly inaccessible & opaque.

    Single payer NOW!

  142. As a Canadian taxpayer who values his reasonably priced and effective taxpayer funded health care, I am continually shocked when I read of the greed, corruption and outright criminality in the U.S. system. But what is even more shocking is that your country seems incapable of cleaning it up!
    If Americans once experienced what it is to have a decent healthcare system they would never give it up.

  143. Oh please give me a break. I'm also a Canadian as are my parents - born and raised. My parents have lived in Atlanta, GA part time for the last 20 years. I'm sick and tired of hearing about our "great" health care system in Canada. It's a lie. Reasonably priced? Yes and it's wonderful to go to the ER and not have to pay; however, if you have a serious illness you're far more likely to die in Canada because of ridiculous many-months (or year+) waits for sometimes important procedures. My parents have Kaiser Permanente (sp.?). When my mother's chronic leukemia became life threatening she was in the hospital for a blood transfusion and chemo within days. When she has blood tests her results are online the same day. The actual doctor or specialist will phone the house to see how things are, to explain results, and answer questions. When she needed knee surgery she waited 10 days. NONE of this would happen in Canada in fact it all sounds like science fiction to me. My mother's knee surgery would have been a two year wait in Canada. When my father was told of a cancer skin patch in Halifax, NS the procedure to treat it would have been more than a year. He had it done in under two weeks upon returning to ATL. And mother's CL? If she were in Canada she would have died I've no doubt. Our system is less expensive, but inferior to the American. Wait times are a *huge* issue that means loss of life for tens of thousands of Canadians each year and it goes unreported.

  144. People need to start challenging outlandish medical bills aggressively. Just because someone sends you a bill of doesn't mean you are obligated to pay it. If you push back they will often back off. If they don't go to small claims court.

  145. How can going to small claims court help you fight an erroneous bill? Sorry I'm not connecting the dots.

  146. You can ask a small claims court to declare that the bill is invalid or to settle a controversy about the amount owed.

  147. I live in Austin Texas. This article speaks to the problem that we have here. My wife gets insurance through her employer, a national healthcare company. She had to go to the ER several years ago, but as it turned out there ER doctors were out of network, so we got blasted for the bill there.

    Earlier this year, I had to go to the ER. Having learned from our previous experience, we went to a different hospital, further away from us, and we still ran into the issue of the ER doctors not being in network.

    We even changed insurance carriers last year in hopes of resolving the issue. But, as it turns out, in Austin Texas, the 11th largest city in the country, with a medical school at the university of Texas, and a plethora of hospitals all over the city, there is no hospital where both the ER services of the hospital and the ER doctors are covered by one insurance company. No matter what hospital we go to, we have to pay out of network for the ER hospital or the ER doctor.

    Me thinks that there is a game being played here. Mr. McConnel and Mr. Cruz can shove their healthcare bills where the sun don't shine.

  148. I'm over 65 and on Medicare. Whenever I have to deal with a new physician or medical group, the first question I ask is whether they accept Medicare assignment, meaning that they accept Medicare's reimbursement as payment in full. If they don't, I keep looking. If they send me an ambush bill, I remind them that they represented themselves as accepting Medicare's rates.

    The vultures in the medical business keep finding new schemes to increase revenue, often by circuitous and opaque means. This will not change until we rid ourselves of these parasites and institute universal, single-payer care. It's just ridiculous what we have to go through now.

  149. Thank you, NYT, for outstanding reporting. I hope the next step is for EmCare to be investigated by the federal government, though the AG may be too busy being 'beleaguered.'

    Who knew health care was so complicated? /sarcasm/

    I truly believe the single most important step in making health care less complicated is to nationalize the entire thing, as the vast majority of developed nations have done. The U.S. is left behind in the dark ages (along with its arcane and non-secular attachment to creationism and not adopting the metric system, but that's a topic for another day).

  150. People being systematically bilked when they are at their most vulnerable. What kind of a nation have we become that we allow institutionalized price-gouging in the health sector? Appalling.

  151. US Health Care - a racket that the Mob would admire. How long this insanity can go on is anybody's guess.

  152. What a mess...

    Unfortunately, money is the universal incentive. No amount of regulation will change that. You can change the rules of the game, but you can't change the players.

    Does anyone really believe switching to single-payer will magically erase the greed of doctors and hospitals?

  153. As a retired Emergency Medicine physician let me point out three things:
    1) Almost all physians who work for contract management groups such as Emcare are salaried so their incomes are not directly impacted by how much is billled in their name by these groups
    2) Most board certified Emergency physicians would prefer not to work for large contract management groups and their shareholders but hospital administrators have chosen to contract with these middlemen and economies of scale for benefits including malpractice insurance leave the physicians little choice. I find the the quarter figure for Emergency Departments staffed by such groups hard too low and know that in South Jersey it approaches 100% other than the large teaching hospital, Cooper.
    3) single payer or other forms of universal coverage would reduce bills as there wouldn't be large percentages of Emergency Department patients who pay nothing for the physician services they receive although before I retired NJ Medicaid hardly covered the per patient cost of malpractice insurance plus billing.

  154. What EmCare is doing is criminal, but doctors are getting the lion's share of the money. Our system lets doctors get away with gigantic bills that bear no relation to their actual efforts. $500 to touch the woman's ankle? Oh, please. A dentist in my town has a "Super Yacht" magazine in his waiting room and was going to charge me $450 for a simple cleaning; talk about blatant greed! It's time for consumers to push back. A market-driven medical system doesn't work well because demand--the need for medical care--can't respond to price. You need help when you need it, regardless of how outrageous the price becomes.

  155. please get your facts right. emcare docs are paid a salary that has little relationship to what corporate emcare collects

  156. Unfettered capitalism at work. The only reason market-based national healthcare works in other countries--where there is profit for hospitals and physicians and drug companies--is fettered capitalism. The national government does what the US states are beginning to do -- set limits on what can be billed. Free markets, left unfettered, result in EmCare and the unlimited profits of healthcare delivery organizations. "Bending the cost curve" in healthcare means profit must be constrained. As it won't be done by the entities, as this article and study shows, it must be done by law.

  157. The small claims court system is rife with cases submitted by "out of network" health providers. Judgements in their favor are rubber stamped. Our taxpayer funded courts have become collection agencies for these shysters and the patient's credit is ruined in the process.

  158. Wouldn't it be nice if our taxpayer funded courts tossed out these miserable claims and sent the EmCare's of the world home empty-handed. Where is their contract with the individuals being sued? No doubt, not transparent to the patient.

  159. Glad to see this get a little press.

    Both Liberals and conservatives have been so focused on access to and funding for healthcare that they've totally ignored the reason it has become such an urgent issue: rising cost. The research of Zach Cooper and his Yale colleagues has yielded some damning conclusions, and they're based on empirical evidence—not theories, predictions, or comparisons between different OECD healthcare systems.

    They've demonstrated that there's absolutely no transparency for consumers, and the lack of scrutiny has allowed healthcare providers to jack up prices. One of their studies showed that the price of the same exact procedure will vary dramatically from hospital to hospital, even within the same metropolitan area, without any correlation with success rates. Because we're in the dark, we can't "shop around" other hospitals or ask our healthcare provider why their price is so different from other hospitals.

    I mean, we get the bill for a procedure but there's no comprehensive, legible breakdown of the costs, and trying to get that info from your insurance or healthcare providers is impossible. How do you know you're not being charged $5 for a 4x4 gauze sponge?

    You don't. You're meant to be in the dark. It's insane to me that consumer advocates on the left and free-market proponents on the right haven't joined forces on this when it seems like the one issue where their interests overlap. I wish the media would make a bigger deal out of it, too.

  160. I'm waiting for Republicans in Congress to get off the backs of all those unmotivated, dependent Americans languishing on cushy welfare payments and go after the bigger pigs: the EmCares and the Health Insurance Companies, the crooked doctors and lawyers.

    If Ryan could just raise his sights a bit he might realize that the hatred and condescension he projects onto everyone who takes advantage of the programs that saved his scrawny little teenager life, might better be directed at the real crooks, the real unproductive takers.

    The scourge of the nation are these Real Good Americans, respected because they're rich and given a pass because they buy a Republican legislator every once in a while. Notably Ryan.

  161. Ryan's life was not "saved" by his SS Survivor benefits -- it's only a few hundred dollars a month -- the Ryan's were wealthy and his late father left a big insurance policy. But EVERYONE gets SS Survivor benefits if the family breadwinner dies -- it is not means tested. So the wealthy Ryan family got the same benefit as anybody -- a welfare mother, Bill Gates -- anyone.

    The benefit went to Ryan's MOTHER -- not Ryan himself, who was a minor child at the time his dad died. Ryan had NO SO-SO about collecting this benefit, and may not have even known about it, since he was a teenager.

    His mother did not need to use the money to live on, so she banked it and used it for her kids college expenses. This seems pretty reasonable to me.

    Whatever else you hate about Ryan....this is a stupid thing to harp on.

  162. This issue of outsourced ER doctors not being "in network" even though practicing in hospitals that are in network has been documented for quite some time.

    So with all due respect to the CEO of this hospital, if he did not address this issue when negotiating with EmCare, than he was negligent in his responsibilities.

  163. "She was shocked to get an additional bill from a doctor who she said never identified himself and only briefly touched her broken ankle. That physician worked for EmCare. Her portion of the bill is more than $500." Such incidents are outright fraud. If the feds paid as much attention to theft by doctors and hospitals as to kids sexting, it might put a small but measurable dent in the runaway cost problem.

  164. Insane. No other part of the economy runs like this. It's like a Rubik's cube inside a jigsaw puzzle. As other commenters have written, single payor is the only solution.

  165. Medicaid HMOs pays 23 -40 dollars in NJ for physician visit. For this you spend 10 minutes seeing and talking to patient and 30 minutes meeting all its unproven requirements. Only 30% of physicians accept it.
    Problems all started when the small private practices ran into ground meeting all the government mandated requirements leading to creation of these behemoths.
    No thanks. We are better off without more government. Rather we should remove regulations and let smaller practices thrive to compete with these behemoths. See how fast the prices will come down.

  166. NY Times, you need to be doing another complementary investigation about how long it takes a doctor to get insurance companies to carry him/her at a new location/ hospital. First you have to get Medicare, which takes 3-4 months at least. Then, once you gave that, you have a pecking order of the ones that cascade down from that in your new hospital. To get all the insurers to allow you to bill them takes a year or more because of the red tape and slowness of the insurance company bureaucracies. It is monstrous the amount of time and effort to get approvals to join networks. There is a whole industry that charges an arm and a leg to do some (just some) of the paperwork for you. Then, every year, you have to do a whole new contract all over again with each one of dozens of insurers. (ER docs don't have staff to do it for them.) Check it out.

  167. Wende Lewis, thank you for this information. I have long wondered how this works for any health care provider. You have, with your description, provided an interesting picture and one that adds more weight to the previous evidence of why we need a better medical care system. It's a shame that doctors and others undergo extensive training only to be sandbagged with requests and requirements that have nothing to do with patient care except the ability of health insurance companies to scam you and the patients. And at the end of all of it there's nothing good for the patient or the doctor unless you count getting an ulcer from the stress and we know who's helped by that.

  168. Pieces of the "why is health care so expensive?" puzzle, July 24 edition: Part 1 is companies like Emcare. Part 2 is the length of time to get into the insurance system per this comment above.

  169. If an ER is part of a hospital, the hospital should have their administrative staff complete this paperwork. The ER should not be a separate entity.

  170. As a healthcare finance executive with 30+ years of experience (primarily on the medical group side) I'll point out something that I've not yet seen in the comments. Simply, the hospital that hires a physician staffing company like EmCare is not (or should not be) naive to the fact that, while they are contracted with the health plans operating in their market, EmCare will not be (nor is it incentivized to be). So, if you and the members of your community are victims of out of network billing take aim at the hospital administrators and Board members that brought an EmCare into your community, that is where the fault lies.

  171. Yes the hospital board is not likely so innocent as the article implies. There is a never arms race between insurer and provider networks. A hospital may be able make a high profit with certain subspecialties (radiology) and loose money on others (psychiatry / pediatrics). They keep the loosing specialties on board in order to have the cache of being a full service hospital and because they can't keep residency programs going without certain core services. Hiring a physician staffing company is just the newest way to off load less profitable (at the in-network rate) areas. The patients are left in the lurch.
    Its interesting but disheartening to see the liberals and conservatives give their take through their own myopic lenses. I think what gets missed is that the market isn't between the patients and doctors. Its between the insurance giants and the health care industry giants. Patients and doctor increasingly feel like road kill.

  172. I was a victim of Emcare, worked for them for 5 years, I never new how much Emcare billed, and collected on my behalf, and my pay varied every month based on some mysterious calculation by Emcare. Finally my partners and I got sick and tired of Emcare, and gave the hospital an ultimatum, either us or Emcare. They chose us, and we have been in the same stable group for the last 10 years.

  173. how did you get out of the non-compete clause in your contract?

  174. the administration fired Emcare and paid them off to release the doctors [only 250K]

  175. Billing abuse. If McConnell actually wanted to do something about the complete failure of the current medical insurance regime, he would replace the entire medical billing system with something sane. He cannot touch the insurance companies because each of those are controlled at the state level. The insurance companies were very clever and avoided federal regulation a long time ago, but the billing departments could be federally regulated. Most of the collectors ought to be in jail. Right now the incentives for the billing companies to overcharge are so extreme they just can't help themselves.

    The real point here is that as the boomers age they will need medical care and every company that can possibly get their hands into the dying boomers pockets and steal all of their money (so that the boomers' children don't inherit anything) are beginning to stick their hands out.

    The GOP is not just failing to take action against the incredibly bad billing actors that are out there but in fact are facilitating the bad actors. Greed Over People party is an understatement.

  176. Problem was created by dems with ACA and excessive CMS Regulations (mandatory EMR, meaningful use, MACRA, MIPS amongst many other unproven regulations) It drove small practices to ground and created these behemoths (like EmCare, Mednax). Any hospital corridor is teeming with people in black suits instead of in white coats all created to run the behemoths created to survive the regulations. Enjoy the benefits.

  177. Also, the picture of the rural hospital with the fawn in the corner is so perfect that it's almost hard to believe it wasn't staged. The photographer deserves a bonus. At least a pizza party.

  178. Until the US implements a single-payer health care system nationwide, this kind of thing will continue unabated. These private companies are like mosquitos, you swat one, a hundred others are waiting to take its place.

  179. Yes, I actually asked my ER Dr. if he was in network when it appeared I may have suffered a stroke. Thank God I was cognizant. In the past I 'imagined' that if the hospital was in network, then the staff would be also. Wrong. On a previous visit I had a renowned cardiologist attend to me, and then also this other young woman who came in and asked me the same things my cardiologist did. I wasn't sure what her role was. I found out: she was there to ad the $800 to my portion bill, four times what I paid for the experienced cardiologist who actually did treat me. So yes please be sure you are not unconscious when you arrive at the ER and be sure and ask every single person who comes anywhere near you: "are you in network? " If not, then even if what sent you to the ER doesn't kill you, the bill, even with insurance, might.

  180. What is the distinction between "inflated bills" and "egregious billing" and fraud and theft? To quote Woody Guthrie: "Some will rob you with a six-gun,
    and some with a fountain pen."

  181. In other words in America it's cheaper to drop dead or go without any treatment. There is pain at either end. Pain when it comes to the actual illness and pain when it comes to the "cost" which, considering the expense and how they go about collecting it, should be called a ransom.

  182. After one "ambush billing" experience of this nature I tried to be careful about checking whether all the ancillary practices associated with an inpatient elective surgical procedure would be in-network. My health insurer's website at the time had a disclaimer that said, more or less, it was not guaranteeing the accuracy of the information on the site as to who was in the network, because the status of any provider could change at any time. So much for trying to be a smart consumer.

  183. Republican Congressmen take note: that the prices negotiated by insurance companies and doctors are secret. How can the free market work with secret prices?

  184. The healthcare business sector spends enormous amounts of money (the most according to OpenSecrets) lobbying our legislators. If citizens only knew half of the inequities that are built into their costs, they'd be appalled. Glad to see NYT exposing some of them.

  185. Yet another reason we need Universal Healthcare!

  186. This is not a new phenomenon. Ask me. I was just billed by a local urgent care 'system' for a lab procedure, outside of the pay up front fee I paid at the time of service, that they never appeared to have actually done, let alone completed. When I asked for them to send me a copy of the result so I could accurately asses that they did the test, they 'couldn't find it'.

    The main problem with hiring these corporate shiester subcontracted billers which operate remotely is that they simply do not match the smaller scale of economic services these small town, rural hospitals operate under. It's not dissimilar to someone using a hammer to kill a fly. Hiring a high overhead, egregiously over paid urban corporation like "EmCare" to (over) bill farmers, laborers, should be considered a form of white collar crime. And, believe me, if we had a single payer system like every other civilized nation, 'EmCare' wouldn't exist.

  187. A piece of the "why is health care so expensive?" puzzle. Keep the info coming, NYT...

  188. Since single payer healthcare is probably years away with the Republican control of our government, let's hope this article is a shot across the bow of high medical costs. Thank you NYT. Having journalists expose these types of experiences of insured patients being blindsided is our only way to know something like this occurs.

  189. FL proves that, if consumers collectively oppose a predatory healthcare practices, the state legislature will respond. If instead of sitting back and complaining, consumers banded together on other health-related issues, real change would happen.

  190. "This is insane, and it's greedy."

    Not to mention unconscionable, bordering on criminal. Also entirely predictable.

    All of these descriptors apply to our current so-called system of health care, which is a system only in the same sense as Ponzi schemes and robbery plots are systems. Even when it's legal, it's appalling--all you have to do is look at any given doctor bill. If we spent half the time and money on providing care as we do on building Taj Mahal hospitals and advertising and coders/billers trained to squeeze every last drop from every turnip/patient, we might, just might, have quality of care akin to what folks enjoy in Scandinavia, Canada and other nations that long ago figured out that private-sector health care simply doesn't work. And at a fraction of the cost.

    Medicare for everyone.

  191. In my view, this clearly shows that a major component of the difficult situation regarding health care is the greed of the insurance companies. The though question is, though, how to tackle it.

  192. This is the greed of the doctor companies.

  193. This is frankly absurd. Short of single payer, it almost has me convinced we need price controls in the medical practice so that everyone pays the same regulated fee for the same procedure regardless of whether there has been a prior agreement with a patient's individual insurer (or whether the patient has insurance).

    That won't ever happen of course, except maybe on a state by state basis.

  194. Stealing from sick, frightened people who come in via the ER is the foundation of the business model.

    Sanders, Warren et al in 2020.

  195. Sanders, Warner et al are part of problem not solution. This situation is created by the ACA that through all the regulations ran all the private practices to ground by making it exorbitantly expensive.
    The void was filled by these guys like Mednax, Emcare etc. Now real the benefits while these guys and the owner of Cerner, HCA, Mednax and EmCare besides others who benefitted laugh their way to the bank.

  196. As a response to G, who thinks staffing companies like Emcare came about after ACA, read the article: Emcare started in the 1970's and this type of billing issue was a
    Problem for years before Obamacare

  197. I recently had a hospital stay after an ER visit as well and a few months after I had paid the hospital bill, a doctor bill like the ones described in your article arrived. Thanks for the research; I'm going to challenge it with my insurance provider (through my employer) as they indicated that I've already met my deductible for the year. I'll use that and this article as leverage.

  198. Only in "exceptional" America are medical billing costs hidden from patients (consumers). The for-profit health care system in the U.S. is the world's most expensive by a very wide margin for this reason, but not with equally stellar results for patients. Quite the opposite, in fact. Republicans are responsible for this, and too many voters don't seem to comprehend the connection. But they will with morally bankrupt Republicans controlling congress and a president without a moral compass or empathy. A failing nation.

    Eclectic Pragmatism — http://eclectic-pragmatist.tumblr.com/
    Eclectic Pragmatist — https://medium.com/eclectic-pragmatism

  199. We spend much more than twice the amount per capita on health care than any other industrialized country.

  200. The public seems incapable to following a cause-and-effect scenario. I give up, actually I gave up in November.

  201. A true market would require price discovery and willingness to freely buy (or sell). Since that is impossible, any reference to healthcare as a market is meaningless. Republicans perpetuate "market solutions" when that is meaningless as Speaker Ryan's statements about "access" to care.

  202. As the Times has reported, coding specialists are now a significant part of the healthcare economy, juicing bills (especially out-of-network) for profit.

    Any real healthcare reform will need to address this. Other countries do so by having collectively-negotiated price controls. Sorry, coding people: it's time for your jobs to disappear.

  203. When you enter an ER you are given a financial responsibility form to sign. Do as I do, and endorse the form with a statement such as "All providers must accept Medicare assignment. Patient refuses care from non-participating providers." Then date and initial the endorsement. (Substitute the name of your own insurer.)

    Also state "Patient not responsible for uncovered services unless advised in advance that services might not be covered and has the choice to decline." Again, initial and date the endorsement.

    You must at least try to protect yourself from greedy companies such as EM.

    To

  204. Sounds great, but won't they just tell you to go elsewhere?

  205. And we still hear that Obamacare is responsible for the rising cost and health insurance are the bad guys. It's amazing that the main players in the industry responsible for the outrageous cost from the hospitals are always forgotten from the media

  206. Yes it is. In the wake of ACA, so many regulations (almost all unproven in any scientific study) were imposed that small practices couldn't survive. In came these kind of behemoths and physicians were forced to join them. It was infact encouraged in the name of uniformity by the previous administration. What it did was led to creation of these large corporations with no competition and what we see today is a result of this (look up your own health system and see who are the highest paid players.....I can tell you almost all are administrators). Other rich people in healthcare.....owners and board members of Cerner, Mednax, HCA, Allscripts, and a host of other regulatory companies.
    and as for insurance companies....ask them why they won't publish their rates. Why is it a secret.

  207. Where the patient is over charged, it is possible to get advice, for instance from the county society. The patient can then remit a reasonable amount, with a letter of explanation. The threat of collection practices and or of an effect on one's credit rating should not deter one from self-protection. No one goes to an emergency room to get fleeced and no company has the right to mistreat a patient or his/her wallet. To overcharges...just say "no"!!

  208. Nice sentiments but "just say no" means months of intensive wrangling and negotiation by phone, letter, email, with your insurance the hospital etc. All while you are sick or newly recovered.

  209. All another reason the US needs a single payer system. Price discrimination (charging patients different prices for the same service/good based on their insurance network) is illegal in nearly every other industry yet it is the cornerstone of the healthcare industry in the US.

    A centralized, single payer system managing billing would be far more efficient and effective for patients, providers, and insurers - the status quo of every provider negotiating prices with every insurance company is unwieldy, inefficient, and ineffective. Providers should focus on care not billing codes, a single payer system would help enable care over coding and collection.

  210. It's called Medicare and it works beautifully, can hardly wait 5 years to enroll!

  211. Good luck.

  212. NY has dealt with this problem quite effectively. The insurer (who is required to pay for emergency services, even if out of network) is required to negotiate with the out of network doctor. If they cannot agree, the bill is submitted to baseball style arbitration. "Baseball style" means that the arbitrator cannot pick a middle ground figure. The arbitrator must choose either the insurer's amount or the doctor's amount. The result has been that we no longer have the insurer offering a ridiculously low amount and the doctor demanding a ridiculously high amount. Both are incentivized to be reasonable - so they don't lose the arbitration.

  213. I once was an inpatient at a New York hospital with pneumonia on top of my asthma and I was saddled with huge bill from a pulmonologist I didn't know. I paid the doctor what the insurance company paid and he agreed even though he wasn't happy about the reduction.

  214. out-of-network surprise bills are not limited to the ER. My sister was in various intensive care units at a huge NYC hospital system as she gradually died of ovarian cancer, and after she died and well after she satisfied her insurance out-of-pocket expenses, the out-of - network bills started arriving, eventually totalling $14K. We fought them, and eventually settled for a lesser amount, but it was immensely complex and stressful. She used the hospital in part because it was in her network, and at no time were we notified that any of her doctors were not In network.

  215. A similar thing happened to my mother. I swear any doctor would stick their head in the door and say "hey, how are you today?" and then a doctor's visit gets added to the bill.

  216. before you let any physician near you, have to remember to ask that question - Are you in my network. It has to become routine for us.

  217. The NYT reported a few years ago in an article on this same old same old topic, that it was normal for some docs to come into the hospital daily, look through the intake records; when they see a name they recognize as perhaps having been a patient, they go up to the room, open the door, and yes, hey how are you today, pause to enter this info into their diary for today, go back to their office and send an invoice to bill the client $1,700 ; in many cases the patient is asleep and is not awoken; many times they are comatose. Why are these doctors not sued for corruption? theft? illegal billing? Somebody - please! why can they get away with this? It is truly despicable. Is that what they teach in medical school??? I care because my kids live in the US and I am in terror for their health care.
    Elizabeth Barry now in Toronto

  218. I recently had an emergency room visit and admittance to Renown hospital. I am enrolled in a Medicare PPO with Humana Insurance. Just received a bill from Renown for $400 for various doctors. Called Humana and was told the doctors were "out of network". This is patently absurd. How is a person supposed to find an "in network" provider when he is laying in a hospital bed? I wonder if anybody has made that argument in court against an insurance company - patently absurd!

  219. I needed emergency treatment in France that involved two physicians (one a plastic surgeon), a number of tests, minor surgery with local anesthetic, and two follow-up visits. I didn't have insurance at the time, but since it was an emergency, my total out of pocket costs were $220. My care was excellent.

    Compared to other countries, US healthcare is in the Dark Ages.

  220. What is your citizenship? Confusing. If you are a US citizen, then that nice outcome is often reported. We have had similar low-cost, low-bureaucracy treatment in Germany.

  221. A monster company, there is no other word to use to describe such a company.

  222. 2 things:
    1) Why is this not front-page news? Forget Kushner. Forget the Russian issue (at least for 5 minutes). Health care is probably the most critical social issue facing Americans today. Many other things in the news are merely sideshows and distractions.
    2) Only 163 comments on this article? Really? This article highlights some of the most egregious problems connected with the health care system in the U.S. and it seems that very few people are paying attention.
    This does not bode well for long-term, positive reform of the system.

  223. You are correct on both points. People don't pay attention to medical costs until there's a medical emergency followed by receipt of the bills. It's truly astounding. When you are laying on a gurney bleeding to death it just doesn't occur to you to ask the doctor whether she's in network or out. Why aren't state's attorneys' general looking in to bring fraud charges for this kind of thing?

  224. Agreed. It is not headline news because Democrats and Republicans are 2 sides of the same coin destroying the country in their own special way...and the media carries the water for them.

  225. Continued greed and madness rule the medical care system. Single payer for all, one system, one card, better results all around.

  226. Not much different out here. With two major health care conglomerates supplying 80% of the services in a 4 state area, woe unto the person who has to go somewhere other than those 2 in an emergency or outside the area. The insurers work hand in glove with the conglomerates to soak every last dime in "out of network" expenses. Worse yet is when even your in network doctor has to refer you to a specialist out of network because the network doesn't have the specialist. It took 6 months to fight them all the way to court and "win" and the doctor was told to seek employment elsewhere, all for doing the correct thing for his patient. A pox on the health care rip off system. All the while, the state insurance commissioner who gets his donations from the conglomerates did absolutely nothing.

  227. There are a lot of people getting rich off of health care, and this is the main reason why there is resistance to change. Physicians make up less than 10% of health care costs. While this article points out the billing of the ED group, one would have to ask, why is it that the insurance company says they are "out of network" in an emergent situation and refuses to cover the cost? Makes no sense. And why does a bag of normal saline cost $875 on average in an ED visit (basically salt water), but the bad guy is the physician who orders it and is charging the patient less than what the hospital is charging for that bag to costs? Don't let big business make physicians the scapegoat as to why health care costs are exorbitant. Have you asked how much the CEO of an insurance company or hospital makes lately? have you wondered why the tylenol you take over the counter or buy at Costco costs $400 when administered in a hospital for "nursing administration fees?" Health care is so broken in this country that it makes it difficult and hard at times to continue to care for patients. I agree there are a lot of people getting very very rich off of the sick, but it's not the physicians. Let's look at insurance companies, pharmaceuticals, and the cost of hospital "administration" if you want to go after the problem, rather than the providers (doctors, nurses, NP's, PA's) who were trained and are dedicated to taking care of the sick.

  228. And Obamacare -- which was supposed to solve everything! -- actually entrenched this "for profit system" and made it worse, with the ACA which was WRITTEN BY AN INSURANCE COMPANY EXECUTIVE.

    Obamacare made this "for profit insurance system" more powerful, more entrenched and impossible to get rid of.

    Obamacare did NOTHING to control costs, but merely soaked the middle class to give 100% FREE Medicaid welfare to able bodied poor people.

    THANKS OBAMA!

  229. Isn't it possible that in order to have viable ERs in undesirable areas you might need to pay a premium for medical care?

  230. There are ways of dealing with underserved areas. Looking for potential medical school applicants who come from rural areas who want to live in those areas, scholarships for those students, and utilizing nurse practitioners and physician assistants are a start. A single payer health care system would help solve the issue as well. Why do insurance company and hospital staffing company shareholders need to make a profit on people's illnesses? Eliminating these middlemen would allow more money to go to the health care providers. Insurance company stocks are some of the fastest growing right now, and the shareholders are making money on all our medical problems. Does that seem right?